Essential Neurological Examination

Chong-hao Zhao, MD, PhDBoard Certified in Neurology, Headache Medicine,

Pain Medicine, and Medical Acupuncture

State of California X-ray Fluoroscopy Supervisor and Operator

Voluntary Teaching Faculty Graduate Orofacial Pain Program at UCLA

California Headache & Pain Center420 W. Las Tunas Dr., San Gabriel, CA

Tel: 626-457-1688; www.chpci.com

Email: Drzhao@chpci.com

UCLA Graduate Orofacial Pain Program Lecture #1, February 7th, 2017

Components of Neurological

Examination

• Mental Status

• Cranial Nerves

• Motor

• Coordination

• Reflexes

• Sensory

• Gait

Mental Status

• Check for orientation x 3

– time

– place

– person

Cranial Nerve 1

• Olfactory nerve:

– Smelling of vinegar

– Usually skip this test

– Skull base lesion

Cranial Nerve 2

• Optic nerve:

– Visual acuity: with eyeglasses if needed, one eye at one time, using the “near card”

– Visual field: Look at examiner’s nose, 50 cm apart, 30 cm above followed by 30 cm below patient’s eye level. Examiner waves the index finger.

– Fundus: Papilledema, optic disk pallor

Approaching the Patient with an

Ophthalmoscope

• The optic disc is 3 to 4 mm to

the nasal side of the fovea

Start 30 cm away, 15 degree from the line of patient’s eye fixation at the same

horizontal plane of the eye, approach until within 1-2 cm of patient’s eye

Fundus AppearanceIntracranial hypertension

Optic neuropathy, pale disc,

e.g. optic neuritis

Cranial Nerve 3

• Oculomotor nerve:

– Eyelids: look for drooping eyelid (levator palpebrae muscle)

– Pupils (sphincter pupillae muscle)• Shape and symmetry: equal size?

• Reactivity to light: Using the swinging flashlight test (optic nerve senses the light, oculomotor nerve constricts the pupils)

– Extraocular movements: to fixate on and follow examiner’s finger in all directions of gaze (inferior and superior rectus, medial rectus, inferior oblique)

Cranial Nerve 4

• Trochlear nerve:

– Superior oblique muscle

– Depression and intortion

of the eye ball. Lesion

causes inferomedial gaze

palsy)

Cranial Nerve 6

• Abducens nerve:

– Lateral rectus muscle

– Lateral gaze

– Lateral gaze palsy raises the suspicion of increased intracranial pressure (e.g. pseudotumor cerebri, exerting downward pressure on the brainstem, causing the nerve to stretch along the clivus which is posterior to the sphenoid sinus. )

CN 3,4,6 – Extraocular Eye Movement

Cranial Nerve 5

• Trigeminal nerve:– Sensory: Check deficits to light touch,

pinprick, and temperature (face, eye, tongue, partly oropharynx)

• V1: Forehead– Also check corneal reflex: light touch

to the cornea with a cotton wisp

• V2: Cheek

• V3: Chin

– Motor: Checking for asymmetry of lateral jaw movements (jaw deviates to the paralyzed side, medial and lateral pterygoid muscles move the jaw from side to side)

V1, 2, 3 and C2, 3 Sensory Distribution (Controversial of C2 and C3 Dermatome)

David L Brown. Atlas of Regional Anesthesia. 1999,

page 137 & 181

V1, 2, 3 and C2, 3 Sensory Distribution

(Controversial of C2 and C3 Dermatome)

Anne M. R. Agur. Grant’s Atlas of Anatomy. 1991, Page 252.

Cranial Nerve 7

• Facial nerve:

– Facial muscle: ask the

patient to raise the

eyebrows, close the eye,

bare the teeth

– Taste: anterior 2/3 of tongue (Right Bell’s Palsy)

Cranial Nerve 8

• Vestibulocochlear nerve:

– Balance: associated with vertigo

– Hearing (use 512 Hz tuning fork):

• Weber’s test: striking the tuning fork and placing it against the middle of the forehead

– Conductive deafness: lateralization to the affected ear, middle ear.

– Sensorineural deafness: lateralization to the better ear, inner ear

• Rinne test: striking the tuning fork and place it on the mastoid process until the tone no longer being heard, then place it over the external auditory meatus

– Conductive deafness: not hear the sound over the external auditory

meatus (bony conduction BC > AC air conduction)

– Sensorineural deafness: still hear the sound over the external

auditory meatus (AC > BC)

Cranial Nerve 9 & 10

• Glossopharyngeal nerve:

– Sensation back of tongue, pharynx, middle ear

– Taste posterior 1/3 tongue

• Vagus nerve:

– Soft palate muscle: soft palate elevation

• Ask the patient to say “Ah”

• Gag reflex:

– CN 9 sensory input

– CN 10 motor output-Ambiguus nucleus.

– Lightly touching the posterior oropharynx with a cotton swab

• May be absent in older patients

Cranial Nerve 11

• Spinal accessory nerve:

– Sternocleidomastoid muscle: head rotation and

tilt to the opposite side

• Flex and turn the head to each side against

resistance

– Trapezius muscle: shoulder elevation.

• Shrug the shoulders against resistance

Cranial Nerve 12

• Hypoglossal nerve:

– Tongue muscle

– Stick out the tongue

• Deviate to the weak side

– Push it into each cheek

Motor

• Muscular bulk: check atrophy (myopathy)

• Muscular tone: look for spasticity (stroke)

• Muscular strength: grade the strength

– 0: no muscle contraction visible

– 1: barely visible muscle contraction

– 2: active movement of part of limb with gravity eliminated

– 3: active movement of part of limb against gravity

– 4: active movement against moderate resistance

• 4 - : against slight resistance

• 4+ : against strong resistance

– 5: normal power

Coordination

• Involving sensory feedback, motor

output, integration center (mainly by

cerebellum)

• Tests:

– Finger-to-nose test:

• Alternatively touch a fingertip to the

nose and examiner’s finger

– Heel-to-shin test:

• Slide the heel up and down the front of

the shin

Reflexes – Deep Tendon Reflex

• Striking the muscle tendon with a reflex hammer

– Increased reflex in upper motor neuron (corticospinal

tract) lesion.

– Decreased in lower motor neuron lesion (motor

neurons, ventral nerve root); peripheral nerve disease;

and muscle diseases.

– Grading:

• 4 + : increase with clonus

• 3 + : increased without clonus

• 2 + : normal

• 1 + : decreased

• 0 : absent

Bicep, Brachioradialis (Supinator),

Triceps Reflex

C5

C6 C7

Patellar and Ankle Jerk (Achilles) Reflex

L3, 4 S1, 2

Reflexes – Plantar Reflex• Bakinski’s sign (upper motor neuron lesion):

– Firmly stroke the sole of the patient’s foot, beginning at the heel and following up the lateral margin and across the ball of the foot to the base of the big toe

– Negative: The toes all flex, is flexor plantar response

– Positive: Big toe extends, the other toes spread, is extensor plantar response

– No response: no toe movement

• Normal, insensitive to test

• Profound motor weakness to extend the big toe

• Sensory abnormality

– Withdrawal response: If big toe extends, the other toes extend and ankle reflexes, need to repeat test more gently

Sensory - Primary Sensory Modalities

• Light touch

• Pinprick

• Temperature

• Vibration (128 HZ)

• Joint position (Proprioception)

Dermatome and Peripheral Nerves

Sensory - Cortical Sensory Modalities

• Graphesthesia:

– The ability to recognize writing on the skin purely by the sensation of touch.

– Close the eye and identify a number traced on the palm

– Positive if cannot identify: contralateral parietal lobe damage, or damage to the dorsal columns pathway at any point between the tested point and the contralateral parietal lobe.

• Stereognosis:

– The ability to perceive and recognize the form of an object using cues from texture, size, spatial properties, and temperature

– Close the eye and identify a key, coin, paperclip

– Test the intact of contralateral parietal lobe, and posterior column

Gait

• Casual walking

• Toe walking: lower extremity strength > 4/5

• Tandem gait test: walk a straight line, touching toe to heel– To test ataxia, cerebellar dysfunction, drunk driving test

• Romberg’s test: stand with feet together and eyes close– Loss of joint positional sense:

• Posterior column: cervical spondylosis, B12 deficiency

• Peripheral neuropathy

– Cannot proceed the test if the patient cannot stand and fall with eye open

• Cerebellar and central/peripheral vestibular syndrome

Suggested Readings:

• Memorix Neurology by Peter Berlit, 1996

• Neurological Examination Made Easy by Geraint

Fuller, 1995

• Clinical Neurological Neuroanatomy Made

Ridiculously Simple, by Stephen Goldberg, 1990